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34 Orthodontics KCE Reports 77 POSTERIOR CROSSBITE Posterior crossbite is defined as any abnormal bucco-lingual relation between opposing molars and/or premolars in centric relation. A difference should be made between an unforced and a forced posterior crossbite. The latter represents a unilateral posterior crossbite as a result of a functional displacement of the mandible. Figure 7: Posterior crossbite Posterior crossbites may develop or improve at any time from when the baby teeth come into the mouth to when the adult teeth come through. Most treatments have been used at each stage of dental development 23 . Posterior crossbites in the primary dentition are relatively common and their causes are numerous. The etiology of a posterior crossbite can include any combination in dental, skeletal and neuromuscular functional components 24 . A posterior crossbite associated with a functional shift of the mandible towards the crossbite side (forced crossbite) occurs in 80 to 97 % of the posterior crossbite cases 24 The frequency of self-correction is 0% to 9%. A forced crossbite is generally considered to be one of the few malocclusions which should be considered for correction in the primary dentition. In 2001 a Cochrane review on the orthodontic treatment for posterior crossbites has been published. 23 The evidence (only from two trials) suggests that removal of premature contacts in the deciduous teeth is effective (in 28/71 treated cases; versus 12/66 untreated cases) in preventing a posterior crossbite from being perpetuated to the mixed and adult dentitions. When grinding alone is not effective, using an upper expansion plate to expand the upper dental arch will decrease the risk of a posterior crossbite from being perpetuated to the mixed and adult dentition. 23 . Because of the small amount of studies, the evidence is only low. In a more recent meta-analysis of immediate changes with rapid maxillary expansion (RME) Lagravere concluded that the greatest change from rapid maxillary expansion are dental and skeletal transverse changes and these changes are clinically relevant 25 . In another systematic review it is also concluded that the long-term stability of transverse skeletal maxillary increase is better in skeletally more mature individuals (pubertal and postpubertal growth peak) than in skeletally less mature (prepubertal growth peak) individuals. Long term transverse skeletal maxillary increase was found to be approximatively 25 % of the total appliance adjustment (dental expansion) in prepubertal children 26 . Another systematic review by the same author on the long term dental arch changes after RPE concluded that a clinically significant long-term maxillary molar arch width increase (3.7 - 4.8mm) and a more consistent maxillary cuspid arch width increase (2.2 – 2.5 mm) can be achieved and this to a similar degree in adolescents and adults. Less mandibular molar and cuspid arch width expansion was attained in adults compared to adolescents. A significant overall gain was found in the maxillary (6mm) and mandibular (4.5mm) arch perimeter in adolescents treated with RPE and edgewise fixed appliances 27 The results of this systematic review are based on 3 studies that all had some methodological flaws; hence the conclusions should be viewed with caution.
KCE Reports 77 Orthodontics 35 No strong conclusions on dental or skeletal changes that occurred after slow maxillary expansion treatment, also due to methodological flaws. Another systematic review on the early orthodontic treatment of unilateral posterior crossbite was performed by Petren et al 28 and found 12 studies meeting inclusion criteria of which only 2 RCT’s (which were also included in the 2001 Cochrane review). They found that the treatment strategies Quad-Helix (QH), expansion plates and RME are effective in the early mixed dentition at a high success rate, but they concluded that due to many methodological weaknesses in the studies, there is no scientific evidence available to show which of the treatment modalities grinding, QH, expansion plates or rapid maxillary expansion is the most effective 28 . Further randomised clinical trials should be performed on the management of crossbites and a difference should be made between an unforced and a forced posterior crossbite. There is evidence for the effectiveness of treatment of posterior crossbite in deciduous teeth; the quality is low. There is evidence for the long-term skeletal effectiveness of rapid maxillary expansion; the quality is low. TOOTH CROWDING AND EXTRACTION OF DECIDUOUS TEETH A protocol for a Cochrane review on the subject of the orthodontic treatment for crowded teeth in children was published in 2007. Crowded teeth develop when there is a lack of space in the jaws for the teeth to erupt in a proper well-aligned manner. Crowded teeth are a common feature for which a patient is seen by an orthodontic practitioner. Throughout the whole orthodontic literature crowding of teeth has been accepted as one of the major (psychosocial, aesthetic) indications for orthodontic treatment by lay people q as well as professionals r . Little evidence on how to deal with this problem seems to be available yet. One RCT was found on extraction of deciduous canines for crowding in the mixed dentition 29 . According to the results, the amount of lower incisor crowding was reduced to a greater extent in the extraction group, suggesting that the molars had migrated forward. However, as there is only 1 chance in 20 that the amount of crowding will improve in the permanent dentition when extractions of deciduous canines are performed, the benefits of extracting lower deciduous canines for the "relief" of lower incisor crowding are questionable 29 DISTURBANCES IN NUMBER(1): DENTAL AGENESIS In the permanent dentition, mandibular secondary premolars are affected most frequently, followed by maxillary lateral incisors and maxillary second premolars s . Bilateral agenesis of maxillary lateral incisors is more frequent than unilateral agenesis. No studies other than case series were found, so no evidence is available on this subject. q Original IOTN: aesthetic index for lay people (however not validated) r Indications de l'Orthopédie Dento-faciale et Dentomaxillofaciale chez l'enfant et l'adolescent (2002) et Recommendations pour la pratique clinique. Les critères d'aboutissement du traîtement d'Orthopédie dento-faciale (2003). Publication par l' Agence Nationale d'Accréditation et d'Evaluation en Santé (ANAES), Service des recommandations professionelles, 159 rue Nationale 75640 Paris-Cedex 13 - Tel 01 42 16 72 72 - Fax 01 42 16 73 73 s Clinical guideline on management of the developing dentition and occlusion in pediatric dentistry. American Academy of Pediatric Dentistry - Professional Association. 2001 (revised 2005). 18 pages. NGC:004439
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